Phthiriasis Palpebrarum: A Rare Clue to Child Abuse

Satyam Jha, B. Optometry, FICO

Consultant Optometrist, Trinetra Eye Centre, Jalpaiguri, India

 

Phthiriasis palpebrarum (lice of eyelashes) is an infestation of the eyelashes by Pthirus pubis (pubic lice) that is rare but important in the field of ophthalmology. Although phthiriasis can arise from inadequate hygienic practice or living in unsanitary conditions, phthiriasis in a child can be considered a red flag of sexual abuse. For these reasons, recognition of phthiriasis is important not only to treat the problem, but to protect a vulnerable patient. ⁽¹⁾

Understanding Phthiriasis Palpebrarum

Phthiriasis palpebrarum is the result of infection with Pthirus pubis, which differs from Pediculus humanus capitis. ⁽³⁾ The parasite most frequently inhabits pubic hair but can also be found on the eyelashes, eyebrows, armpit hair, and chest. ⁽³⁾ Transmission in adults occurs primarily through sexual contact, while in children it is usually due to contact with contaminated linens, towels, clothing, or close contact with an infected person. ⁽³⁾

Clinical Signs and Symptoms

Patients with phthiriasis palpebrarum often experience continuous irritation and itching of the eyes, with redness and inflammation of the eyelid margins. ⁽¹⁾ Physical findings reveal the parasites and their eggs—translucent or brownish oval-shaped structures occurring close to the lash line or base of the eyelashes. ⁽³⁾ Lice excrements may accumulate along the eyelid margins, causing dark crusts and occasionally bacterial infections from scratching. ⁽⁴⁾ Slit-lamp examination confirms diagnosis by visual identification of lice and their eggs. ^(1,4)

Figure 1: Signs of phthiriasis palpebrarum

Figure 2: Steps of Diagnostic Confirmation

A Red Flag for Child Abuse

Adult parasitism with Phthirus pubis is typically related to sexual contact. ⁽³⁾ However, when phthiriasis palpebrarum is seen in children, particularly those under 10 years of age, it raises serious concern. ⁽³⁾ Because sexual transmission is the most common mode for Pthirus pubis, finding lice on a child’s eyelashes should be strongly interpreted as a possible sign of abuse, demanding immediate investigation. ⁽²⁾

Figure 3: Red flag indicators for child abuse

Key Point: If the child or guardian cannot reasonably explain how the lice were acquired (e.g., shared bedding or poor hygiene), involvement of child protection services may be necessary. ⁽³⁾

The Responsibility of Healthcare Workers

The eye care specialists and the doctors who take care of children are the best and the closest people to the patients suffering from phthiriasis palpebrarum whom they could not only manage but also protect. It is their responsibility to collect, through the questioning, a complete environmental history that would involve hygiene and living conditions in the house and the possible sources from which the victim might have been exposed to. ⁽⁵⁾ A thorough examination should be the first step taken not only for the confirmation of the diagnosis but also for the revelation of new signs of abuse, like bruises, genital infections, and behavior changes. ⁽⁵⁾ The healthcare professionals must make the decision to report the issue of concern of abuse to the child protection agencies when such suspicions arise. This is the process that immediately takes place in order to keep the patient safe, just like the prescribing of eye drops that is done to take care of the clinical need. ⁽³⁾

Figure 4: The role of healthcare workers

Treatment Options

Management of phthiriasis palpebrarum has various methods depending on the condition and severity. The removal of lice and nits manually using fine-tipped forceps under magnification is, most of the time, the initial stage of treatment. ⁽²⁾ Local treatment like petroleum jelly containing ophthalmic ointment and an antibiotic formulation may be used; petroleum jelly is the agent to suffocate the lice, whereas antibiotic ointments, although of limited effectiveness, can play a role in lowering secondary infections. ^(2,5) If a case is resistant to treatment or the infestation has become generalized, the oral ivermectin may be given; ⁽⁴⁾ however, it must be always done under strict clinical supervision and proper follow-up. ⁽⁵⁾ Moreover, informing the close contacts and the thorough cleaning of the potentially contaminated items such as bed linen, towels, and clothes for avoiding the old ones of infestation is very necessary. ⁽⁵⁾

Figure 5: Treatment options

Conclusion

Phthiriasis palpebrarum is more than an unusual eyelid infestation—it can serve as a silent alarm for child abuse. Early recognition, careful evaluation, and prompt action by ophthalmologists, optometrists, and paediatricians are vital for not only clinical recovery but also ensuring child safety. ^(1,4)

 

References

1. Gurnani, B., Badri, T., & Hafsi, W. (2024). Phthiriasis palpebrarum. Authored by the MD Searchlight Team. Link
2. Yuan, F., Tang, D., & Zhou, Z. (2025). Phthiriasis palpebrarum: A systematic review and illustrative case presentation. European Journal of Ophthalmology. https://doi.org/10.1177/11206721251371361
3. Ryan, M. F. (2014). Phthiriasis palpebrarum infection: A concern for child abuse. The Journal of Emergency Medicine, 46(6), e159–e162.
4. Dredge, J. H., Winter, T. W., & Alset, A. E. (2019). Phthiriasis palpebrarum treated with oral ivermectin. Ophthalmology, 126(6), 791.
5. Wu, N., Zhang, H., & Sun, F. Y. (2017). Phthiriasis palpebrarum: A case of eyelash infestation with Pthirus pubis. Experimental and Therapeutic Medicine, 13(5), 2000–2002.